Prior Authorization Help Optimize Patient Outcomes by Encouraging Use of Therapies With Established Evidence of Efficacy and Safety

By AMCP CEO Susan A. Cantrell, RPh, CAE
Prior authorization (PA) is a crucial but often-misunderstood utilization management tool in the pharmacy benefit space. The bad rap that PAs have received recently, I believe, comes from either misinformation about the process or glitches in specific systems that can easily be corrected.

AMCP represents thousands of pharmacists and other health care professionals who design and implement pharmacy benefits for millions of Americans. PA is an essential part the equation.

Every day our members design and implement PAs that help optimize patient outcomes by encouraging the use of therapies that have established evidence of efficacy and safety, and provide the highest value. PAs help reduce waste, error and unnecessary medication use and costs.

One example is PAs for powerful painkillers. Today’s addiction crisis has been fueled in part by inappropriate and over-prescribing of opioids and other medications with addictive properties. PA programs involving opioids provide an additional level of safeguard to ensure the patient receives the appropriate medication for his or her condition, while avoiding unnecessary risks.

Another common example of PA is for the drug Botox. The medicine is used to treat muscular disorders, but it also can be used for cosmetic purposes (e.g., eliminate wrinkles). If a health plan does not cover cosmetic products or procedures, a PA would ensure that Botox is covered only when it’s used for appropriate medical indications.

Prior authorizations are not designed to save money to the detriment of patient care. Costs are considered only after safety and efficacy are first considered to determine appropriate clinical use.

While we strongly believe in this utilization management tool, we know that more can be done to improve the PA process. On this front, AMCP has taken a lead role in supporting the National Council for Prescription Drug Programs SCRIPT standard-based electronic prior authorization (ePA). This standard improves the patient and prescriber experience by providing real-time responses to PA processes.

In addition, we are continually assessing best practices. The AMCP Professional Practice Committee recently published “Prior Authorization and Utilization Management Concepts in Managed Care Pharmacy” in AMCP’s Journal of Managed Care & Specialty Pharmacy. Nine specific concepts the committee developed for effective PA practices focus on: (1) patient safety and appropriate medication use, (2) clinical decision making, (3) evidence-based review criteria, (4) automated decision support, (5) transparency and advanced notice, (6) emergency access, (7) provider collaboration, (8) need for timeliness and avoiding disruptions in therapy, and (9) cost-effectiveness and value. I encourage you to read this important document.

I am proud to say that members take AMCP’s vision seriously: “Optimizing medicines. Improving lives.” And I also note that we too are patients and caregivers, and we agree that everyone deserves timely and efficient access to appropriate therapy. That is our commitment with PA programs.